Evaluation of propofol-ketamine anesthesia for children undergoing cardiac catheterization procedures

Propofol versus Ketofol for Sedation of Pediatric Patients Undergoing Transcatheter Pulmonary Valve Implantation: A Double-blind Randomized Study

OBJECTIVE

The study was done to compare propofol and ketofol for sedation of pediatric patients scheduled for elective pulmonary valve implantation in a catheterization laboratory.

DESIGN

This was a double-blind randomized study.

SETTING

This study was conducted in Prince Sultan Cardiac Centre, Saudi Arabia.

PATIENTS AND METHODS

The study included 60 pediatric patients with pulmonary regurge undergoing pulmonary valve implantation.

INTERVENTION

The study included sixty patients, classified into two groups (n = 30). Group A: Propofol was administered as a bolus dose (1-2 mg/kg) and then a continuous infusion of 50-100 μg/kg/min titrated as needed. Group B: Ketofol was administered 1-2 mg/kg and then infusion of 20-60 μg/kg/min. The medication was prepared by the nursing staff and given to anesthetist blindly.

MEASUREMENTS

The monitors included heart rate, mean arterial blood pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, fentanyl dose, antiemetic medications, and Aldrete score.

MAIN RESULTS

The comparison of heart rate, mean arterial pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, and Aldrete score were insignificant (P > 0.05). The total fentanyl increased in Group A more than Group B (P = 0.045). The required antiemetic drugs increased in Group A patients more than Group B (P = 0.020). The durations of full recovery and in the postanesthesia care unit were longer in Group A than Group B (P = 0.013, P < 0.001, respectively).

CONCLUSION

The use of propofol and ketofol is safe and effective for sedation of pediatric patients undergoing pulmonary valve implantation in a catheterization laboratory. However, ketofol has many advantages more than the propofol. Ketofol has a rapid onset of sedation, a rapid recovery time, decreased incidence of nausea and vomiting and leads to rapid discharge of patients from the postanesthesia care unit.

Diagnostic Cardiac Catheterization in the Pediatric Population

Although the utility of diagnostic cardiac catheterization in the clinical setting has diminished over the last years, due to the emergence of noninvasive imaging modalities, such as echocardiography, magnetic resonance imaging and computed tomography, catheterization for diagnostic reasons still constitutes a valuable tool in certain parts in the workup of pediatric heart disease. As a result, awareness of the main aspects of diagnostic catheterization is of great importance for the clinical cardiologist. In this article, the main variables measured and the main actions performed during diagnostic cardiac catheterization in children are discussed.

Deep sedation in GreenLight laser prostatectomy

Introduction:

Evaluation of ketamine and propofol combination for the performance of photoselective vaporization of prostate (PVP).

Patients and Methods:

Twenty-six patients undergoing PVP for benign prostatic hyperplasia were included in the study. Co-morbidities were present in 24 patients. Midazolam 2 mg intravenous was administered for the induction to anesthesia. Propofol (10 mg/ml) and ketamine (1 mg/ml) were administered with the use of two pumps. An initial bolus dose of 0.03 ml/kg of propofol and 5 mg of ketamine was administered intravenously. The anesthesia was maintained by continuous infusion of 0.01 ml/kg/min of propofol and 2 ml/min of ketamine. Fentanyl was administered when deemed necessary. The level of sedation, peri-operative parameters and side-effects were recorded.

Results:

The average periods from the induction of anesthesia and intraoperative infusion were 12.38 ± 5.84 min and 59.5 ± 22.15 min, respectively. Average propofol and total ketamine dose were 85.5 ± 10.62 μg/kg/min and 144.9 ± 45.62 mg, respectively. The average dose of fentanyl administered was 29.81 ± 27.40 μcg. An average period between the end of the infusion and the discharge to the urology clinic was 34.62 ± 22.89 min. Ten patients experienced nausea and five eventually vomited. Hallucinations were observed in five cases while visual disturbances in two patients.

Conclusion:

The combined use of ketamine and propofol for the performance of PVP proved to be an efficient method for anesthesia. The “deep sedation” provided by these drugs was not associated with significant side-effects. Moreover, the use of the above method is indicated in patients with significant co-morbidities that should undergo PVP.

Sedation for paediatric transcatheter atrial septal defect closure: comparison of two sedation protocols

AIM

This study aimed to compare the effects of dexmedetomidine-propofol and ketamine-propofol sedation on haemodynamic stability, immobility, and recovery time in children who underwent transcatheter closure of atrial septal defects.

METHODS

In all, 46 children scheduled for transcatheter closure of atrial septal defects (n = 46) were included. The dexmedetomidine-propofol group (n = 23) received dexmedetomidine (1 μg/kg) and propofol (1 mg/kg) for induction, followed by dexmedetomidine (0.5 μg/kg/hour) and propofol (100 μg/kg/minute) for maintenance. The ketamine-propofol group (n = 23) received ketamine (1 mg/kg) and propofol (1 mg/kg) for induction, followed by ketamine (1 mg/kg) and propofol (100 μg/kg/minute) for maintenance.

RESULTS

In all, 11 patients in the dexmedetomidine group (47.8%) and one patient (4.3%) in the ketamine group demonstrated a decrease ≥20% from the baseline in mean arterial pressure (p = 0.01). Heart rates decreased ≥20% from the baseline value in 10 patients (43.4%) in the dexmedetomidine group and three patients (13%) in the ketamine group (p = 0.047). Heart rate values were observed to be lower in the dexmedetomidine group throughout the procedure after the first 10 minutes. The number of patients requiring additional propofol was higher in the dexmedetomidine group (p = 0.01). The recovery times were similar in the two groups--15.86 ± 6.50 minutes in the dexmedetomidine group and 19.65 ± 8.19 minutes in the ketamine group; p = 0.09.

CONCLUSION

The ketamine-propofol combination was less likely to induce haemodynamic instability, with no significant change in recovery times, compared with the dexmedetomidine-propofol combination. The ketamine-propofol combination provided good conditions for the intervention.

The use of basic parameters for monitoring the haemodynamic effects of midazolam and ketamine as opposed to propofol during cardiac catheterization

OBJECTIVE

Our aim is to compare the haemodynamic and adverse effects of propofol versus the mixture of midazolam and ketamine as used in sedation for cardiac catheterization in children.

METHODS

In a prospective randomized trial, we divided patients needing sedation into 72 receiving a mixture of midazolam and ketamine and 42 receiving propofol. Their ages ranged from 6 months to 12 years, and 1 year to 16 years, respectively. We collected data relative to heart rate, mean arterial pressure, respiratory rate, peripheral saturations of oxygen, and adverse effects. We assessed cyanotic patients to establish any relationship between the haemodynamic data and peripheral arterial saturations of oxygen.

RESULTS

Demographic data, including age, gender, and weight, was not statistically different between the groups. In those receiving midazolam and ketamine, mean systemic arterial pressures before, and 30 minutes after, sedation were 64.3, with standard deviation of 9.8, and 62.5, with standard deviation of 10.2, millimetre of mercury (p equals to 0.237). Heart rates were 131.3, with standard deviation of 13.5, and 109.2, with standard deviation of 17.3 beats per minute, (p less than 0.001) whereas in those given propofol the comparable values were 71.2, with standard deviation of 14.4, and 53.6 with standard deviation of 9.7 millimetres of mercury (p less than 0.001), and 115.2, with standard deviation of 13.6, and 100.5 with standard deviation of 20.1 beats per minute (p less than 0.01), respectively. Mean systemic arterial pressures in the subgroups of cyanotic patients before and 30 minutes after sedation were 74.8, with standard deviation of 14.6, and 72.7, with standard deviation of 12.4 millimetres of mercury for those receiving midazolam and ketamine (p equals to 0.544), and heart rates were 119.3, with standard deviation of 12.2, and 104.6 with standard deviation of 16.1 beats per minute (p equals to 0.001). In those given propofol, the comparable values were 71.1 with deviation of 15.5 and 53.9 with deviation of 9.2 millimetres of mercury (p equals to 0.001), and 126.7 with deviation of 20.8 and 107.2 with deviation of 13.5 beats per minute (p equals to 0.001), respectively.

CONCLUSIONS

In cyanotic children, propofol used as a sedative agent during cardiac catheterization causes a decrease in mean arterial pressure and arterial desaturation. Ketamine produces more stable haemodynamic data in children with congenitally malformed hearts.

Is the addition of dexmedetomidine to a ketamine-propofol combination in pediatric cardiac catheterization sedation useful?

Pediatric patients undergoing cardiac catheterization usually need deep sedation. In this study, 60 children were randomly allocated to receive sedation with either a ketamine-propofol combination (KP group, n = 30) or a ketamine-propofol-dexmedetomidine combination (KPD group, n = 30). Both groups received 1 mg/kg of ketamine and 1 mg/kg of propofol for induction of sedation, and the KPD group received an additional 1 μg/kg of dexmedetomidine infusion during 5 min for induction of sedation and a maintenance infusion of 0.5 μg/kg/h. In both groups, 0.2 mg/kg of propofol was administered as a bolus to maintain a Ramsey sedation score (RSS) greater than 4 throughout the procedure. None of the patients in either group required intubation. In the KP group, one patient required mask ventilation. The chin-lift maneuver needed to be performed for eight patients in the KP group and one patient in the KPD group (p < 0.05). Adding dexmedetomidine to the ketamine-propofol combination decreased movement during the procedures. The heart rate in the KPD group was significantly lower after induction of sedation and throughout the procedure (p < 0.05). No significant differences in systolic blood pressure, diastolic blood pressure, or respiration rates were found between the two groups (p > 0.05). The mean recovery time was longer in the KP group (5.86 vs 3.13 min; p < 0.05). Adding dexmedetomidine to a ketamine-propofol combination led to a reduced need for airway intervention and to decreased movement during local anesthetic infiltration and throughout the procedure. The recovery time was shorter and hemodynamic stability good in the KPD group.

Current approaches to pediatric heart catheterizations

Sedation for pediatric cardiac catheterization is a common requirement in many institutions. As the field of cardiac catheterization has evolved, the provision of sedation for these procedures has been varied. Increasingly the demand is for dedicated personnel focused on monitoring and delivery of sedation while in the catheterization suite. This article describes the considerations one must use when undertaking these cases.